Patient-physician interaction in general practice and health inequalities in a multidisciplinary study: design, methods and feasibility in the French INTERMEDE study

Interaction between patient and general practitioner according to the patient body weight: a cross-sectional survey

OBJECTIVE

To analyse whether patient-general practitioner (GP) interaction, measured by their disagreement, varies among overweight or obese patients compared with normal-weight patients.

METHODS

Twenty-seven GPs and 585 patients participated in the quantitative phase of the multidisciplinary INTERMEDE project and answered "mirrored" questionnaires collecting both GPs and patients' perceptions on information and advice given at the end of the consultation. Multilevel logistic regressions were performed to explore associations between patient body mass index (BMI) and patient-GP disagreement on information and advice given during the consultation.

RESULTS

Disagreement increased with the patients' excess weight, and it was particularly pronounced for advice given by GPs on weight and lifestyle issues. Compared with patients with a "normal" BMI, overweight patients were more likely to disagree with their GP regarding advice given on weight loss (odds ratio [OR] = 10.7, 95% confidence interval [CI] = 4.1-27.3), advice given on doing more physical activity (OR = 1.9, 95% CI = 1.1-3.4), and nutritional advice (OR = 2.9, 95% CI = 1.5-5.6).

CONCLUSION

These disagreements could degrade the quality of patient-physician relationship. Our study provides an opportunity for GPs to reflect on how they communicate with overweight and obese patients, particularly with regard to lifestyle and weight-related advice and interventions taking into account the patient's representations.

Patient-centred e-health supports value cocreation and quality of medical care in Taiwan

BACKGROUND

Patient-centred e-health (PCEH) focusses on the interaction between patients and physicians. However, only a limited number of studies have focussed on the design of physician-patient value cocreation mechanisms in the PCEH context. Thus, we extend Grönroos' concept of value cocreation to understand how PCEH might improve the quality of care.

OBJECTIVES

This study proposes a theoretical framework to embody PCEH-supported value cocreation and presents some empirical validation. We expect that PCEH-supported value cocreation should comprise capabilities for patient empowerment, intention for information sharing, complementation for checking and verifying information, and interaction for shared understanding.

METHODS

This study surveyed a small group of patients that have used PCEH, 'My Health Bank' in Taiwan. The questionnaires were delivered to patients in hospitals (n = 167 questionnaires, 98% response rate).

RESULTS

Results indicate that certain PCEH-supported value cocreation mechanisms-capabilities for patient empowerment and interaction for shared understanding-affect the perceived quality of medical care.

LIMITATIONS

The survey only considered patient perceptions of value cocreation.

CONCLUSION

This study shows the patient perception of value cocreation in patient-centred e-Health. Further research needs to validate the framework for health professionals and in other e-Health record information sharing settings.

Comparing GPs' risk attitudes for their own health and for their patients' : a troubling discrepancy?

Background

In this paper, we report the results of risk attitudes elicitation of a French general practitioners national representative sample (N=1568).

Methods

Willingness to take risks in four different domains (daily life, financial matters, own health and patient health) was collected through a large-scale telephone interview of GPs using self-reported 11-point Likert scale questions.

Results

We uncover some specificities of the GPs population regarding their attitudes towards risk. In particular, we detect an important positive gap between their willingness to take risks in the domain of their own health and in the domain of the heath of their patients. This “patient-regarding” risk aversion is discussed with respect to its important consequences regarding medical behavior bias.

Conclusions

We confirm the self-other discrepancy found in the medical literature on physicians’ behaviors and emphasize the utility of the study and measures of personality traits such as “risk attitudes” for the medical professions and for the population they address.

Integrating Multidisciplinary Results to Produce New Knowledge About the Physician-Patient Relationship: A Methodology Applied to the INTERMEDE Project

The INTERMEDE Project brought together a number of research teams to study the interaction between a patient and their general practitioner, and how this can produce social inequalities in health. The ultimate objective of the project was to formalize a core of common findings by integrating qualitative and quantitative results. The methodology chosen for the integration was inspired by the Delphi participatory method. It involves several rounds of questions and feedback in writing between all members of project teams, in order to compare contradictory opinions and identify key concepts arising from the project. This interdisciplinary research has provided a more nuanced understanding of the mechanisms underlying physician-patient interaction by revealing the convergences of the various disciplinary approaches.

Quality of doctor-patient communication through the eyes of the patient: variation according to the patient's educational level

Good doctor-patient communication may lead to better compliance, higher patient satisfaction, and finally, better health. Although the social variance in how physicians and patients communicate is clearly demonstrated, little is known about what patients with different educational attainments actually prefer in doctor-patient communication. In this study we describe patients' perspective in doctor-patient communication according to their educational level, and to what extent these perspectives lean towards the expert opinion on doctor-patient communication. In a multi-center study (Belgium, The Netherlands, UK and Italy), focus group discussions were organised using videotaped medical consultations. A mixed methods approach was used to analyse the data. Firstly, a difference in perspective in communication style was found between the lower educated participants versus the middle and higher educated participants. Secondly, lower educated participants referred positively most to aspects related to the affective/emotional area of the medical consultation, followed by the task-oriented/problem-focused area. Middle and higher educated participants positively referred most to the task-oriented/problem-focused area. The competency of the physician was an important category of communication for all participants, independent of social background. The results indicate that the preferences of lower educated participants lean more towards the expert opinion in doctor-patient communication than the middle and higher educated participants. Patients' educational level seems to influence their perspective on communication style and should be taken into account by physicians. Further quantitative research is needed to confirm these results.

Do gender differences affect the doctor-patient interaction during consultations in general practice? Results from the INTERMEDE study

OBJECTIVE

The aim of the study was to ascertain whether disagreement between GPs and patients on advice given on nutrition, exercise and weight loss is related to patient-doctor gender discordance. Our hypothesis is that a patient interacting with a physician of the same gender may perceive more social proximity, notably on health care beliefs and may be more inclined to trust them.

METHODS

The analysis used the Intermede project's quantitative data collected via mirrored questionnaires at the end of the consultation. Multilevel logistic regressions were carried out to explore associations between patient-doctor gender discordance and their disagreement on advice given during the consultation adjusted on patients' and physicians' characteristics. The sample consists of 585 eligible patients and 27 GPs.

RESULTS

Disagreement on advice given on nutrition was observed less often for female concordant dyads: OR = 0.25 (95% CI = 0.08-0.78), and for female doctors-male patients dyads: OR = 0.24 (95% CI = 0.07-0.84), taking the male concordant dyads as reference. For advice given on exercise, disagreement was found less often for female concordant dyads OR = 0.38 (95% CI = 0.15-0.98) and an interdoctor effect was found (P < 0.05). For advice given on weight loss, the probability of disagreement was significantly increased (OR: 2.87 95% CI = 1.29-6.41) when consultations consisted of female patient and male GP.

CONCLUSION

Patient-doctor gender concordance/discordance is associated with their agreement/disagreement on advice given during the consultation. Physicians need to be conscious that their own demographic characteristics and perceptions might influence the quality of prevention counseling delivered to their patients.

Disparities in access to health care in three French regions

OBJECTIVES

This paper compares access to primary and specialty care in three metropolitan regions of France: Ile de France (IDF), Nord-Pas-de-Calais (NPC) and Provence-Alpes-Côte d'Azur (PACA); and identifies the factors that contribute to disparities in access to care within and among these regions.

METHODS

To assess access to primary care, we compare variation among residence-based, age-adjusted hospital discharge rates for ambulatory care sensitive conditions (ASC). To assess access on one dimension of specialty care, we compare residence-based, age-adjusted hospital discharge rates for revascularization - bypass surgery and angioplasty - among patients diagnosed with ischemic heart disease (IHD). In addition, for each region we rely on a multilevel generalized linear mixed effect model to identify a range of individual and area-level factors that affect the discharge rates for ASC and revascularization.

RESULTS

In comparison with other large metropolitan regions, in France, access to primary care is greater in Paris and its surrounding region (IDF) than in NPC but worse than in PACA. With regard to revascularization, after controlling for the burden of IHD, use of services is highest in PACA followed by IDF and NPC. In all three regions, disparities in access are much greater for revascularization than for ASC. Residents of low-income areas and those who are treated in public hospitals have poorer access to primary care and revascularizations. In addition, the odds of hospitalization for ASC and revascularization are higher for men. Finally, people who are treated in public hospitals, have poorer access to primary care and revascularization services than those who are admitted for ASC and revascularization services in private hospitals.

CONCLUSIONS

Within each region, we find significant income disparities among geographic areas in access to primary care as well as revascularization. Even within a national health insurance system that minimizes the financial barriers to health care and has one of the highest rates of spending on health care in Europe, the challenge of minimizing these disparities remains.

Instrumental and socioemotional communications in doctor-patient interactions in urban and rural clinics

Background

Location of practice, such as working in a rural or urban clinic, may influence how physicians communicate with their patients. This exploratory pilot study examines the communication styles used during doctor-patient interactions in urban and rural family practice settings in Western Canada.

Methods

We analyzed observation and interview data from four physicians practicing in these different locations. Using a grounded theory approach, communications were categorized as either instrumental or socioemotional. Instrumental communication refers to “cure-oriented interactions” and tends to be more task-oriented focusing on the patient’s health concerns and reason for the appointment. In contrast, socioemotional communication refers to more “care-oriented interactions” that may make the patient feel comfortable, relieve patient anxiety and build a trusting relationship.

Results

The physicians in small, rural towns appear to know their patients and their families on a more personal level and outside of their office, and engage in more socioemotional communications compared to those practicing in suburban clinics in a large urban centre. Knowing patients outside the clinic seems to change the nature of the doctor-patient interaction, and, in turn, the doctor-patient relationship itself. Interactions between urban doctors and their patients had a mixture of instrumental and socioemotional communications, while interactions between rural doctors and their patients tended to be highly interpersonal, often involving considerable socioemotional communication and relationship-building.

Conclusions

Despite the different ways that doctors and patients communicate with each other in the two settings, rural and urban doctors spend approximately the same amount of time with their patients. Thus, greater use of socioemotional communication by rural doctors, which may ease patient anxiety and increase patient trust, did not appear to add extra time to the patient visit. Research suggests that socioemotional communication may ultimately lead to better patient outcomes, which implies that health differences between rural and urban settings could be linked to differences in doctor-patient communication styles.

Is perceived social distance between the patient and the general practitioner related to their disagreement on patient's health status?

OBJECTIVE

To ascertain whether disagreement between patients and general practitioners (GP) on the patient's health status varies according to their respective perceived social distance (PSD).

METHODS

The analysis used the Intermede project's quantitative data collected from 585 patients and 27 doctors via mirrored questionnaires. GPs and patients ranked their own perceived social position (PSP) in society, and their patients' and their GP respectively. PSD was calculated as the PSP's subtraction from the patients' and GPs' assessments.

RESULTS

Disagreement between GPs and patients regarding the patient's health status was associated with PSD by the GP whereas it was not associated with PSD by the patient. In the multilevel analysis, disagreement whereby GPs overestimate patient's health status increased within PSD by the GP: OR:2.9 (95%CI = 1.0-8.6, p = 0.055) for low PSD, OR:3.4 (95%CI = 1.1-10.2, p < 0.05) for moderate PSD and OR:3.8 (95%CI = 1.1-13.1, p < 0.05) for high PSD (reference: no distance).

CONCLUSIONS

Patients perceived with a lower social position by their GP and who consider themselves to have poor health are less likely to be identified in the primary care system.

PRACTICE IMPLICATIONS

Physicians need to be conscious that their own perception influences the quality of the interaction with their patients, potentially resulting in unequal health care trajectories.

Do general practitioners overestimate the health of their patients with lower education?

This study sought to ascertain whether disagreement between patients and physicians on the patients' health status varies according to patients' education level. INTERMEDE is a cross-sectional multicentre study. Data were collected from both patients and doctors via pre- and post consultation questionnaires at the GP's office over a two-week period in October 2007 in 3 regions of France. The sample consists of 585 eligible patients (61% women) and 27 GPs. A significant association between agreement/disagreement between GP and patient on the patient's health status and patient's education level was observed: 75% of patients with a high education level agreed with their GP compared to 50% of patients with a low level of education. Patients and GPs disagreed where patients with the lowest education level said that their health was worse relative to their doctor's evaluation 37% of the time, versus 16% and 14% for those with a medium or high education level respectively. A multilevel multivariate analysis revealed that patients with a low educational level and medium educational level respectively were at higher risk of being overestimated by GP's in respect of self-reported health even if controlling for confounders. These findings suggest that people with a lower education level who consider themselves to have poor health are less reliably identified as such in the primary care system. This could potentially result in lack of advice and treatment for these patients and ultimately the maintenance of health inequalities.

Do doctors and patients agree on cardiovascular-risk management recommendations post-consultation? The INTERMEDE study

BACKGROUND

Understanding interactions between patients and GPs may be important for optimising communication during consultations and improving health promotion, notably in the management of cardiovascular risk factors.

AIM

To explore the agreement between physicians and patients on the management of cardiovascular risk factors, and whether potential disagreement is linked to the patient's educational level.

DESIGN OF STUDY

INTERMEDE is a cross-sectional study with data collection occurring at GPs' offices over a 2-week period in October 2007 in France.

METHOD

Data were collected from both patients and doctors respectively via pre- and post-consultation questionnaires that were 'mirrored', meaning that GPs and patients were presented with the same questions.

RESULTS

The sample consisted of 585 eligible patients (61% females) and 27 GPs. Agreement between patients and GPs was better for tangible aspects of the consultation, such as measuring blood pressure (κ = 0.84, standard deviation [SD] = 0.04), compared to abstract elements, like advising the patient on nutrition (κ = 0.36, SD = 0.04), and on exercise (κ = 0.56, SD = 0.04). Patients' age was closely related to level of education: half of those without any qualification were older than 65 years. The statistical association between education and agreement between physicians and patients disappeared after adjustment for age, but a trend remained.

CONCLUSION

This study reveals misunderstandings between patients and GPs on the content of the consultation, especially for health-promotion outcomes. Taking patients' social characteristics into account, notably age and educational level, could improve mutual understanding between patients and GPs, and therefore, the quality of care.